UNICEF Innocenti Research Centre CHANGING A HARMFUL SOCIAL CONVENTION: FEMALE GENITAL MUTILATION/CUTTING
CHANGING A HARMFUL SOCIAL CONVENTION: FEMALE GENITAL MUTILATION/CUTTING
The opinions expressed are those of the authors and editors and do not necessarily reflect the policies or views of UNICEF. Editor: Alexia Lewnes Front cover picture: UNICEF/MENA/2004/1301/Ellen Gruenbaum Layout: Bernard & Co, Siena, Italy Printed by ABC Tipografia, Sesto Fiorentino, Italy 2005 United Nations Children s Fund (UNICEF) ISBN: 88-89129-24-7 ISSN: 1028-3528 Reprinted in May 2008 ii
Acknowledgments UNICEF Innocenti Research Centre in Florence, Italy, was established in 1988 to strengthen the research capability of the United Nations Children Fund and to support its advocacy for children worldwide. The Centre (formally known as the International Child Development Centre) helps to identify and research current and future areas of UNICEF s work. Its prime objectives are to improve international understanding of issues relating to children s rights and to help facilitate the full implementation of the United Nations Convention on the Rights of the Child in both industrialized and developing countries. The s are produced by the Centre to provide reliable and accessible information on specific rights issues. This issue of the has been principally researched and written by Michael Miller and Francesca Moneti with additional research contributions by Camilla Landini. It was prepared under the guidance of the Centre s Director, Marta Santos Pais. Administrative support was provided by Claire Akehurst. The Communication and Partnership Unit are thanked for moving this document through the production process. Special thanks to Samira Ahmed, Farida Ali, Daniela Colombo, Maria Gabriella De Vita, Malik Diagne, Neil Ford, Gerry Mackie, Molly Melching, Rada Noeva, Cristiana Scoppa, Mamadou Wane and Stan Yoder for their expert contribution, support and counsel throughout. This publication has benefited from the input of participants in the consultation on FGM/C held at UNICEF Innocenti Research Centre in October 2004. These include Zewdie Abegaz, Heli Bathija, Nafissatou Diop, Amna Hassan, Khady Koita, Edilberto Loaiza, Diye Ndiaye, Eiman Sharief and Nadra Zaki. It was also enriched by input from the technical meeting on FGM/C, organized by UNICEF New York Child Protection Section and hosted by UNICEF IRC in October 2004. UNICEF Innocenti Research Centre is grateful to the Dutch, Spanish and Swiss National Committees for UNICEF for additional information, and to UNICEF country and regional offices in Eastern and Southern Africa, Middle East and North Africa, and West and Central Africa for their input and support. UNICEF Innocenti Research Centre gratefully acknowledges the financial support provided to the Centre and specifically for this project by the Government of Italy as well as the financial contribution provided by the Government of Japan. Previous Digest titles include: _ Ombudswork for Children _ Children and Violence _ Juvenile Justice _ Intercountry Adoption _ Child Domestic Work _ Domestic Violence against Women and Girls _ Early Marriage: Child Spouses _ Independent Institutions Protecting Children s Rights _ Birth Registration: Right from the Start _ Poverty and Exclusion among Urban Children _ Ensuring the Rights of Indigenous Children For further information and to download these and other publications, please visit the website at www.unicef-irc.org or, to order publications, contact florenceorders@unicef.org The Centre s publications are contributions to a global debate on child rights issues and include a wide range of opinions. For that reason, the Centre may produce publications that do not necessarily reflect UNICEF policies or approaches on some topics. The views expressed are those of the authors and are published by the Centre in order to stimulate further dialogue on child rights. Extracts from this publication may be freely reproduced, provided that due acknowledgement is given to the source and to UNICEF. The Centre invites comments on the content and layout of the Digest and suggestions on how it could be improved as an information tool. All correspondence should be addressed to: UNICEF Innocenti Research Centre Piazza SS. Annunziata, 12 50122 Florence, Italy Tel: (+39) 055 20 330 Fax: (+39) 055 20 33 220 Email general: florence@unicef.org Email publication orders: florenceorders@unicef.org Website: www.unicef-irc.org (downloadable version of this report is available online) iii
Mona Omar, social worker in an awareness raising session on FGM, holding a poster that says from the medical perspective, FGM is the most harmful practice. Nazlet Ebeed district in Menya, Upper Egypt at Better Life Association UNICEF/Egypt/2005/838/Pirozzi
TABLE OF CONTENTS Foreword...................................................................................vii 1. Introduction...............................................................................1 What is FGM/C? 2. Magnitude, Assessment and Measurement.....................................................3 Where is FGM/C practiced?.....................................................................3 Disaggregated data...........................................................................5 The circumstances surrounding FGM/C......................................................................6 FGM/C and changes over time..................................................................7 Standardizing indicators for situation analysis and monitoring progress...............................8 3. The Social Dynamics of FGM/C...............................................................11 Mechanisms that reinforce the social convention..................................................11 Changing the social convention: towards the abandonment of FGM/C................................13 Abandoning FGM/C: six key elements for change.................................................13 4. FGM/C and Human Rights..................................................................15 FGM/C and the rights of the child...............................................................15 Best interests of the child and the right of the child to respect for his or her views................................15 The rights to life and to the highest attainable standard of health...............................................16 Freedom from physical or mental violence, injury or abuse....................................................18 State obligations............................................................................18 5. Community-based Actions..................................................................23 Changing the social convention: from theory to practice...........................................23 Facilitating dialogue and non-judgmental discussion..............................................25 Alternative rites of passage...................................................................26 Alternative employment opportunities for traditional excisers.......................................26 Working with migrant communities in industrialised countries.....................................27 6. Creating an Enabling Environment for Change.................................................29 National legislation..........................................................................29 Regional standards..........................................................................30 Raising awareness and promoting dialogue.....................................................31 Integrating the abandonment of FGM/C in government programmes.................................31 Coordinating actions.........................................................................32 7. Conclusions...............................................................................35 Links......................................................................................37 v
BOXES Box 1 - Classification of FGM/C types............................................................2 Box 2 - Demographic and Health Surveys and Multiple Indicator Cluster Surveys.......................5 Box 3 - FGM/C and footbinding: a path to marriage and improved social status.......................12 Box 4 - Statements from Islamic and Coptic church leaders.........................................12 Box 5 - A mother s story: Challenges faced by those who begin the process of change..................13 Box 6 - The emergence of FGM/C as a human rights issue..........................................16 Box 7 - The trend towards medicalization and symbolic interventions..............................17 Box 8 - Some recent concluding observations from the Committee on the Rights of the Child regarding FGM/C...............................................19 Box 9 - Organized diffusion begins in Senegal...................................................24 Box 10 - Communication for social change.......................................................25 Box 11 - Nantoondiral: using film to stimulate discussion..........................................26 Box 12 - Legal responses to FGM/C in Western Europe.............................................30 Box 13 - TAMWA media campaigns in Tanzania...................................................31 Box 14 - The United Nations increasing engagement with FGM/C and other harmful traditional practices..33 MAPS Map 1 Countries in which FGM/C is practiced.....................................................4 Map 2 Central African Republic, 2000............................................................5 TABLE Table 1 - FGM/C prevalence among women aged 15 to 49 by country.................................4 Table 2 - Prevalence (per cent) of FGM/C among daughters, by mother s education......................6 Table 3 - FGM/C prevalence in countries where two DHS surveys have been conducted..................7 vi
FOREWORD Every year, three million girls and women are subjected to genital mutilation/cutting, a dangerous and potentially life-threatening procedure that causes unspeakable pain and suffering.this practice violates girls and women s basic human rights, denying them of their physical and mental integrity, their right to freedom from violence and discrimination, and in the most extreme case, of their life. Female genital mutilation/cutting (FGM/C) is a global concern. Not only is it practiced among communities in Africa and the Middle East, but also in immigrant communities throughout the world. Moreover, recent data reveal that it occurs on a much larger scale than previously thought. It continues to be one of the most persistent, pervasive and silently endured human rights violations. This examines the social dynamics of FGM/C. In communities where it is practiced, FGM/C is an important part of girls and women s cultural gender identity. The procedure imparts a sense of pride, of coming of age and a feeling of community membership. Moreover, not conforming to the practice stigmatizes and isolates girls and their families, resulting in the loss of their social status. This deeply entrenched social convention is so powerful that parents are willing to have their daughters cut because they want the best for their children and because of social pressure within their community. The social expectations surrounding FGM/C represent a major obstacle to families who might otherwise wish to abandon the practice. Taking this as its point of departure, the Digest presents some of the most promising strategies to support communities to abandon FGM/C. These approaches recognize that the decision to abandon the practice must come from communities themselves, and must reflect a collective choice, reinforced publicly and grounded on a firm human rights foundation. Greater understanding of human rights provides communities with the tools to direct their own social transformation. The explicitly collective dimension empowers individual families, while liberating them from having to make the difficult choice of breaking with tradition. This is a contribution to a growing movement to end the practice of FGM/C around the world. As early as 1952, the UN Commission on Human Rights adopted a resolution on the issue. The 1979 Convention on the Elimination of All Forms of Discrimination Against Women was an important milestone in recognizing the human rights implications of FGM/C. With the 1989 Convention on the Rights of the Child, the procedure has been identified as both a harmful traditional practice that compromises a child s right to the highest attainable standard of health and a form of violence. The issue has received consistent attention from the Committee on the Rights of the Child and from other treaty bodies and human rights mechanisms. International commitment to address FGM/C continues to grow. The Millennium Development Goals establish measurable targets and indicators of development that are of direct relevance to ending FGM/C namely to promote gender equality and empower women, to reduce child mortality and to improve maternal health. A World Fit for Children, the outcome document of the 2002 UN General Assembly Special Session for Children, explicitly calls for an end to harmful traditional or customary practices, such as vii
early and forced marriage and female genital mutilation. Some countries may be able to achieve this target if adequate resources are provided, while others can make significant advances towards that aim. The current UN Special Studies in Violence against Children and Violence Against Women offer new and important opportunities to draw attention to the issue and generate action to transform this goal into a reality. Never before has the global community had such a refined understanding of why FGM/C persists and encouraging evidence from innovative programmes. There is good reason to be optimistic that by applying this knowledge, FGM/C can become unacceptable from any point of view and in any form, and that the practice can be ended within a single generation. Marta Santos Pais Director Innocenti Research Centre viii
1INTRODUCTION There are an estimated 130 million girls and women alive today whose human rights have been violated by female genital mutilation/cutting (FGM/C). This harmful practice not only affects girls and women in Africa and the Middle East, where it has been traditionally carried out, but also touches the lives of girls and women living in migrant communities in industrialized countries. Although concerted advocacy work over recent decades has generated widespread commitment to end this practice, success in eliminating FGM/C has been limited with some significant exceptions. This meets a pressing need to take stock of progress to date, identify persistent challenges, and highlight the most effective approaches to end FGM/C. In the context of human rights, it integrates concrete field experience with academic theory to provide the global community with a greater understanding of why FGM/C persists. This harmful practice is a deeply entrenched social convention: when it is practiced, girls and their families acquire social status and respect. Failure to perform FGM/C brings shame and exclusion. Understanding how and why FGM/C persists is crucial for developing strategies that are most likely to lead to the abandonment of the practice. This is intended to serve as a practical tool to bring about positive change for girls and women. It: analyses the most current data to illustrate the geographic distribution of FGM/C and outlines key trends; identifies the principal ways in which FGM/C violates a girl s or woman s human rights, including the serious physical, psychological and social implications of this harmful practice; examines the factors that contribute to perpetuating FGM/C; and outlines effective and complementary action at the community, national and international levels to support the abandonment of FGM/C. On the basis of analysis conducted, there is good reason to be optimistic that, with the appropriate support, FGM/C can be ended in many practicing communities within a single generation. What is FGM/C? Female genital mutilation/cutting includes a range of practices involving the complete or partial removal or alteration of the external genitalia for nonmedical reasons. 1 This procedure may involve the use of unsterilised, makeshift or rudimentary tools. The terminology applied to this procedure has undergone a number of important evolutions. When the practice first came to be known beyond the societies in which it was traditionally carried out, it was generally referred to as female circumcision. This term, however, draws a direct parallel with male circumcision and, as a result, creates confusion between these two distinct practices. In the case of girls and women, the phenomenon is a manifestation of deep-rooted gender inequality that assigns them an inferior position in society and has profound physical and social consequences. 2 This is not the case for male circumcision, which may help to prevent the transmission of HIV/AIDS. 3 The expression female genital mutilation (FGM) gained growing support in the late 1970s. The word mutilation not only establishes a clear linguistic Introduction 1
distinction with male circumcision, but also, due to its strong negative connotations, emphasizes the gravity of the act. In 1990, this term was adopted at the third conference of the Inter African Committee on Traditional Practices Affecting the Health of Women and Children (IAC) in Addis Ababa. 4 In 1991, WHO recommended that the United Nations adopt this terminology and subsequently, it has been widely used in UN documents. The use of the word mutilation reinforces the idea that this practice is a violation of girls and women s human rights, and thereby helps promote national and international advocacy towards its abandonment. At the community level, however, the term can be problematic. Local languages generally use the less judgmental cutting to describe the practice; parents understandably resent the suggestion that they are mutilating their daughters. In this spirit, in 1999, the UN Special Rapporteur on Traditional Practices called for tact and patience regarding activities in this area and drew attention to the risk of demonizing certain cultures, religions and communities. 5 As a result, the term cutting has increasingly come to be used to avoid alienating communities. To capture the significance of the term mutilation at the policy level and, at the same time, in recognition of the importance of employing nonjudgmental terminology with practicing communities, the expression female genital mutilation/cutting (FGM/C) is used throughout this Digest. Box 1 - Classification of FGM/C types The specific form that FGM/C takes can vary widely from one community to another. WHO is currently reviewing the 1997 classification of types of FGM/C 6 in collaboration with UNICEF, the United Nations Population Fund (UNFPA) and the United Nations Development Fund for Women (UNIFEM). The new version identifies five types of FGM/C. 7 There are difficulties associated with any classification. Girls and women may not always be certain of which procedure was performed on them. In cases where they were cut at an early age, girls may not even recall undergoing FGM/C. Moreover, there may be significant variation in the extent of cutting, because the procedure is commonly carried out without anaesthetic in poorly lit conditions, and girls often struggle to resist. Notes 1 Shell-Duncan, Bettina and Ylva Hernlund, eds, (2000), Female Circumcision in Africa: Culture, Controversy and Change, Lynne Rienner Publisher, London. WHO also offers a definition of FGM/C, however this is under revision at the time of writing. See WHO/UNFPA/UNICEF (1997), Female genital mutilation. A Joint WHO/UNICEF/UNFPA statement, World Health Organization, Geneva. 2 Yoder, P. Stanley, Noureddine Abderrahim and Arlinda Zhuzhuni, Female Genital Cutting in the Demographic and Health Surveys: A Critical and Comparative Analysis, DHS Comparative Reports No. 7, September 2004, ORC Macro. 3 Reynolds SJ, Sheperd ME, Risbud AR, Gangakhedkar RR, Brookmeyer RS, Divekar AD, Mehendale SM, Bollinger RC (2004) Male circumcision and risk of HIV-1 and other sexually transmitted infections in India, The Lancet, Mar 27, 2004; 363(9414); 1039-40. 4 Shell-Duncan, Bettina and Ylva Hernlund, eds, (2000), Female Circumcision in Africa: Culture, Controversy and Change, Lynne Rienner Publisher, London. 5 Third report on the situation regarding the elimination of traditional practices affecting the health of women and the girl child, produced by Mrs. Halima Embarek Warzazi pursuant to Sub-Commission resolution 1998/16, Commission on Human Rights, Sub-Commission on Prevention of Discrimination and Protection of Minorities, E/CN.4/Sub.2/1999/14, 9 July 1999. 6 WHO/UNFPA/UNICEF (1997), Female genital mutilation. A Joint WHO/UNICEF/UNFPA statement, World Health Organization, Geneva. 7 In its current draft form, Type I refers to excision of the prepuce with partial or total excision of the clitoris (clitoridectomy); Type II refers to partial or total excision of the labia minora, including the stitching or sealing of it, with or without the excision of part or all of the clitoris; Type III indicates excision of part or most of the external genitalia and stitching/narrowing or sealing of the labia majora - often referred to as infibulation ; Type IV makes specific reference to a range of miscellaneous or unclassified practices, including stretching of the clitoris and/or labia, cauterization by burning of the clitoris and surrounding tissues, scraping (angurya cuts) of the vaginal orifice or cutting (gishiri cuts) of the vagina, and introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purposes of tightening or narrowing it; Type V refers to symbolic practices that involve the nicking or pricking of the clitoris to release a few drops of blood. 2 Introduction
2MAGNITUDE, ASSESSMENT AND MEASUREMENT According to a WHO estimate, between 100 and 140 million women and girls in the world have undergone some form of FGM/C. 1 Although overall figures are difficult to estimate, they do indicate the massive scale of this human rights violation. FGM/C affects far more women than previously thought. Recent analysis reveals that some three million girls and women are cut each year on the African continent (Sub-Saharan Africa, Egypt and Sudan). 2 Of these, nearly half are from two countries: Egypt and Ethiopia. Although this figure is significantly higher than the previous estimate of two million, this new figure does not reflect increased incidence, but is a more accurate estimate drawn from a greater availability of data. Effective efforts to end this practice require a more detailed picture of this situation. Where is FGM/C practiced? The majority of girls and women at risk of undergoing FGM/C live in some 28 countries in Africa and the Middle East (see map 1). In Africa, these countries form a broad band from Senegal in the west to Somalia in the east. Some communities on the Red Sea coast of Yemen are also known to practice FGM/C, and there are reports, but no clear evidence, of a limited incidence in Jordan, Oman, the Occupied Palestinian Territories (Gaza) and in certain Kurdish communities in Iraq. The practice has also been reported among certain populations in India, Indonesia, and Malaysia. 3 The most reliable and extensive data on prevalence and nature of FGM/C are provided by Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) (see box 2). Prevalence is defined as the percentage of women aged 15 to 49 who have undergone some form of FGM/C. Obtaining data on FGM/C prevalence among girls under 15 years of age poses a number of methodological challenges, not least of which includes ascertaining if and how the procedure was carried out. Currently DHS and MICS data on FGM/C prevalence are available for 18 countries (see map 1). The most current data from these sources, summarized in table 1, indicate that the prevalence of FGM/C varies significantly from one country to another from as low as 5 per cent in Niger to as much as 99 per cent in Guinea. 4 Countries in which FGM/C is practiced but for which there are not, as yet, DHS or MICS data are Cameroon 5, the Democratic Republic of Congo, Djibouti, Gambia, Guinea Bissau, Liberia, Senegal, Sierra Leone, Somalia, Togo, and Uganda. The latter countries also demonstrate a wide range of prevalence: the Democratic Republic of Congo is thought to have less than 5 per cent prevalence, while both Djibouti and Somalia are estimated to have prevalence around or above 90 per cent. Patterns of FGM/C prevalence emerge when countries are grouped by region. For example, in the countries of northeast Africa (Egypt, Eritrea, Ethiopia, and Sudan), it ranges from 80 to 97 per cent, while in East Africa (Kenya and Tanzania) it is markedly lower and ranges from 18 to 32 per cent. 6 Care is required, however, when interpreting these figures, since they represent national averages and do not reflect the often marked variation in prevalence in different parts of a given country. In Nigeria, for example, national prevalence is 19 per cent; prevalence in the southern regions reaches almost 60 per cent, while in the north it is between zero and 2 per cent. Magnitude, Assessment and Measurement 3
Map 1 - Countries in which FGM/C is practiced FGM/C practiced, DHS or MICS data available FGM/C practiced, no DHS or MICS data FGM/C not practiced Table 1 - FGM/C prevalence among women aged 15 to 49 by country 7 Country Survey type National prevalence and date FGM/C % Benin DHS 2001 17 Burkina Faso DHS 2003 77 Central African MICS 2000 36 Republic Chad (provisional) DHS 2004 45 Côte d Ivoire DHS 1998-9 45 Egypt * DHS 2003 97 Eritrea DHS 2002 89 Ethiopia DHS 2000 80 Ghana DHS 2003 5 Guinea DHS 1999 99 Kenya DHS 2003 32 Mali DHS 2001 92 Mauritania DHS 2000-1 71 Niger DHS 1998 5 Nigeria DHS 2003 19 Sudan* + MICS 2000 90 Tanzania DHS 1996 18 Yemen* DHS 1997 23 * Sample consisted of ever-married women + Surveys were conducted in northern Sudan. The practice of FGM/C is no longer restricted to countries in which it has been traditionally practiced. Migration from Africa to industrialized countries has been an enduring characteristic of the post World War II period, and many of the migrants come from countries that practice FGM/C. Beyond economic factors, migratory patterns have frequently reflected links established in the colonial past. For instance, citizens from Benin, Chad, Guinea, Mali, Niger and Senegal have often chosen France as their destination, while many Kenyan, Nigerian and Ugandan citizens have migrated to the United Kingdom. In the 1970s, war, civil unrest and drought in a number of African states, including Eritrea, Ethiopia and Somalia, resulted in an influx of refugees to Western Europe, where some countries, such as Norway and Sweden, had been relatively unaffected by migration up to that point. Beyond Western Europe, Canada and the USA in North America, and Australia and New Zealand in Australasia also host women and children who have been subjected to FGM/C, and are home to others who are at risk of undergoing this procedure. Data on the prevalence and characteristics of FGM/C in industrialized countries are rare and extrapolations are sometimes used to gain insights on the extent of the practice. By combining data from the office of migration with data on prevalence from countries of origin, the Swiss National Committee for UNICEF estimated that, in Switzerland, some 6,700 girls and women have either undergone FGM/C, or are at risk of undergoing the procedure. Of these, more than one third are of Somali origin. This number does not include women and girls holding a Swiss passport. 4 Magnitude, Assessment and Measurement
Box 2 - Demographic and Health Surveys and Multiple Indicator Cluster Surveys The principal source of data and data analysis on FGM/C is provided by MEASURE DHS+, which assists developing countries worldwide in the collection and use of data to monitor and evaluate population, health, and nutrition programmes. Demographic and Health Surveys provide national and sub-national data on family planning, maternal and child health, child survival, HIV/AIDS/sexually transmitted infections, infectious diseases, reproductive health and nutrition. 8 Additional optional modules address women s status, domestic violence, HIV/AIDS and FGM/C. A module on FGM/C was first included in a survey of northern Sudan in 1989-90, and by the end of 2003, a total of 17 countries (16 in Africa, plus Yemen) had included questions on FGM/C in their surveys. 9 This module represents an important tool for standardizing reporting, monitoring progress and establishing goals in countries where FGM/C remains a challenge. Although the form and emphasis of the questions asked in the surveys have evolved over time, they have generally sought to establish if a woman has undergone FGM/C and, if so, the age of the woman at the time of the procedure, the type of surgery and by whom it was performed. Additional questions also determine whether the respondent s daughter has undergone the operation and, again, the circumstances of this event (generally this refers to the proportion of women aged 15-49 with at least one circumcised daughter, although several studies capture the status of the oldest daughter only). Finally, a number of questions have helped to establish the respondent s attitude towards the practice. Since the survey population is women aged 15-49, 10 in communities where girls undergo cutting at a very young age, the picture presented by DHS data does not necessarily reflect current prevalence. Data on a girl cut at age five, for example, would be recorded ten years later. DHS data are complemented by UNICEF Multiple Indicator Cluster Surveys (MICS). These have a similar structure to DHS surveys and are designed to provide an affordable, fast and reliable household survey system in situations where there are no other reliable sources of data. The first round of MICS was conducted as part of the review of progress made in achieving the goals of the World Summit for Children in 1990 and the second (MICS2) as end decade surveys in 66 countries. The latter were used to inform the UN General Assembly Special Session on Children, held in New York in 2002. MICS, with a module on FGM/C, were carried out in the Central African Republic, Chad and Sudan in 2000, and a new round MICS3 is planned for 2005. Disaggregated data 11 Both DHS and MICS permit national level data to be disaggregated by age group, urban-rural residence and region or province. Many surveys also show differences in prevalence by ethnicity and religion. The possibility of analysing disaggregated data on prevalence is of crucial importance since national averages can disguise significant in-country variations. This is less the case in countries where the prevalence of FGM/C is very high, such as Egypt, Guinea and Sudan, with prevalence rates of 90 per cent or over. However, in countries where a significant proportion of the population does not pursue the practice, disaggregation can significantly enhance understanding of the phenomenon and inform programmatic interventions to support its abandonment. The value of disaggregation by region or province is illustrated by the case of the Central African Republic (map 2), where data from MICS2 indicate that, at the national level, 36 per cent of women aged 15 to 49 have undergone FGM/C. Looking at the situation from a sub-national perspective reveals significant geographic variations. In five prefectures in the west of the country and two in the east, FGM/C prevalence Map 2 - Central African Republic, 2000 Prevalence of FGM 0-19.9% 20-39.9% 40-54.9% 55-69.9% 70-84.9% 85-100% Magnitude, Assessment and Measurement 5
is between 0 and 19.9 per cent, while in three prefectures in the north of the country, the prevalence is between 85 and 100 per cent. 12 The variation is largely explained by the presence of diverse ethnic communities with differing attitudes and practices regarding FGM/C. In the Central African Republic, countrywide FGM/C prevalence ranges from 5 per cent among the Mboum and Zande-N zakara to 75 per cent among the Banda, one of the largest ethnic groups in the country. Among the Gbaya, the largest ethnic group, the prevalence rate is 24 per cent. DHS analysts point out that data vary far more by ethnicity than by any other social or demographic variable. In other words, ethnic identity and the practice of FGM/C are closely linked. Some groups rarely or never practice FGM/C, while in others, virtually all women have been cut. Data on ethnicity are available for only a limited number of countries, and when analysing them, at least three important issues need to be considered. First, ethnic groupings rarely correspond to clearly defined national administrative divisions, and groups that practice FGM/C may be present in a number of provinces or districts. Second, even in a relatively detailed survey, the ethnic groups listed may in fact be an ethnic category consisting of many subgroups with differing practices. Finally, while the disaggregation of FGM/C prevalence by ethnicity is useful for informing programmatic action, these data should be interpreted with care to avoid stigmatization. Urban development has been considered as a possible factor influencing prevalence, although the link between urbanization and prevalence is not unequivocal. Of the 18 countries covered by DHS or MICS, 12 demonstrate a higher prevalence of FGM/C in rural areas than in urban areas, although in certain cases the difference is very small. In two cases (Ethiopia and Guinea), urban and rural rates were both found to be identical or near identical, while in four cases (Burkina Faso, Nigeria, Sudan and Yemen), prevalence in urban areas is higher than in rural parts of the country, a phenomenon most likely explained by the confounding effect of ethnicity. Education, especially of women, can play an important role in safeguarding the human rights of both women themselves, and those of their children. Overall, daughters of mothers who are more highly educated are less likely to have undergone FGM/C than daughters of mothers with little or no education. 13 This is illustrated by the data in table 2. Only in Guinea does no relationship appear between the FGM/C status of daughters and a mother s level of education, a finding which can largely be explained by the very small proportion of women in this country with secondary schooling or above. Table 2 also shows that although there is a statistical difference between women with secondary education and those with no education, FGM/C is still practiced by women with higher education. In other words, women s education may contribute to a reduction of the practice, but alone it is not sufficient to lead to its abandonment. Table 2 - Prevalence (per cent) of FGM/C among daughters, by mother s education 14 Survey No education Primary Secondary Total Benin 11.1 2.5 0.7 8. 2 (2001) Egypt 64.7 62.6 21.2 4 9. 5 (2000) Eritrea 67.5 59.4 40.0 6 2. 5 (2002) Ethiopia 55.7 35.4 25.4 5 1. 8 (2000) Guinea 54.7 44.0 55.1 5 3. 9 (1999) Mali 73.1 73.9 64.8 7 2. 8 (2001) Mauritania 77.4 60.6 41.1 7 0. 9 (2000-01) Yemen 41.4 23.9 29.0 3 8. 3 (1997) The circumstances surrounding FGM/C DHS and MICS provide valuable information regarding the circumstances surrounding the act of FGM/C, including the age at which a girl or woman is subjected to the practice, the type of cutting involved and the practitioner who carried it out. These surveys reveal notable variations in both the form and meaning of FGM/C variations which largely occur between different groups rather than within groups. The age at which large proportions of girls are cut varies greatly from one country to another. About 90 per cent of girls in Egypt are cut between the ages of 5 and 14 years, 15 while in Ethiopia, Mali and Mauritania, 60 per cent or more of girls surveyed underwent the procedure before their fifth birthday. 16 In Yemen, the Demographic and Health Survey carried out in 1997 found that as many as 76 per cent of girls underwent FGM/C in their first two weeks of life. In-country variations are also apparent, often reflecting the distribution of ethnic groups. In Sudan, a cohort study in 2004 found that at least 75 per cent of girls had undergone FGM/C by the age of 9 to 10 in South Darfur, a state which has a predominantly Fur and Arab population, while in Kassala, which has a predominantly Beja population, 75 per cent of girls had already been cut by the age of 4 to 5. 17 Information regarding the type of FGM/C performed is useful in helping to anticipate the extent of the physical consequences of the practice. There are, however, certain challenges in obtaining these data, including ascertaining whether survey respondents understood what was meant when asked about which type of FGM/C they had undergone. In the majority of countries where DHS or MICS included a question regarding type of FGM/C, the lightest form 18 was found to be most common. Only in Burkina Faso was the more extensive procedure, involving excision of the labia minora, most frequently carried 6 Magnitude, Assessment and Measurement
out (accounting for 56 per cent of all cutting 19 ). Infibulation cutting followed by stitching or narrowing was found to affect large proportions of women in two countries: Sudan, where the MICS2 survey in 2000 estimated that as many as 74 per cent of women who had been cut had undergone this procedure; and Eritrea, where the DHS survey in 2002 estimated that 39 per cent had been subjected to infibulation. This procedure is also known to be widely practiced in Djibouti and Somalia. The large majority of girls and women are cut by a traditional practitioner, a category which includes local specialists (cutters or exciseuses), traditional birth attendants and, generally, older members of the community, usually women. This is true for over 80 percent of the girls who undergo the practice in Benin, Burkina Faso, Côte d Ivoire, Eritrea, Ethiopia, Guinea, Mali, Niger, Tanzania and Yemen. In most countries, medical personnel, including doctors, nurses and certified midwives, are not widely involved in the practice. Egypt offers a clear exception: in 2000, it was estimated that in 61 per cent of cases, FGM/C had been carried out by medical personnel. The share of FGM/C carried out by medical personnel has also been found to be relatively high in Sudan 20 (36 per cent) and Kenya (34 per cent). FGM/C and changes over time FGM/C is an evolving practice, and its characteristics and distribution have changed over time. In Yemen, for instance, the practice only emerged in the course of the 20 th century as a result of contacts with practicing communities in the Horn of Africa. Evidence of changes in the prevalence of FGM/C can be obtained by comparing the experiences of women in different age groups in a given country. Using this method, 9 of the 16 countries in which DHS has collected data demonstrate a marked decrease in prevalence in the younger age groups (15 to 25 years of age): Benin, Burkina Faso, Central African Republic, Eritrea, Ethiopia, Kenya, Nigeria, Tanzania and Yemen. In the remaining seven countries (Côte d Ivoire, Egypt, Guinea, Mali, Mauritania, Niger and Sudan 21 ) prevalence is at roughly the same level for all age groups, suggesting that rates of FGM/C in these cases have remained relatively stable over recent decades. Of the four countries that demonstrate the highest rates of prevalence (Egypt, Guinea, Mali and Sudan 22 ) none have shown any evidence of change in prevalence over time. Changes in prevalence can also be assessed in a number of countries where two surveys have been carried out, thus enabling a comparison of results at different points in time. Table 3 indicates that of the seven countries where this type of comparison is currently possible, there has been a clear decrease in overall prevalence in Eritrea, Kenya and Nigeria. The data provide grounds for cautious optimism. Asked if they think that FGM/C should continue, younger women are generally less likely to agree than older women. This difference was highest for Table 3 - FGM/C prevalence in countries where two DHS surveys have been conducted 23 Country Survey Date FGM/C Prevalence (%) Burkina Faso 1998-99 7 1. 6 Burkina Faso 2003 76.6 Côte d Ivoire 1994 4 2. 7 Côte d Ivoire 1998-99 44.5 Egypt 1995 9 7. 0 Egypt 2000 97.3 Eritrea 1995 9 4. 5 Eritrea 2002 88.7 Kenya 1998 3 7. 6 Kenya 2003 33.7 Mali 1995-96 9 3. 7 Mali 2001 91.6 Nigeria 1999 2 5. 1 Nigeria 2003 19.0 the DHS survey in Eritrea in 2002, which found that 63 per cent of women between 45 and 49 years of age supported FGM/C compared to only 36 per cent of women between 15 and 19 years of age. While these findings are encouraging, attitudes may shift with age. Moreover, field experience indicates that a lack of support for FGM/C (i.e. a change of attitude towards the practice) is not always translated into a change in behaviour. In addition to changes in prevalence, there are three significant trends which are emerging in a number of countries where FGM/C is practiced. 24 The average age at which a girl is subjected to cutting is decreasing in some countries. Of the 16 countries surveyed by DHS, the median age at the time FGM/C was performed has dropped substantially in Burkina Faso, Côte d Ivoire, Egypt, Kenya and Mali. Reasons for this may include the effect of national legislation to prohibit FGM/C, which has encouraged the practice to be carried out at an early age when it can be more easily hidden from the authorities. It is also possible that the trend is influenced by a desire on the part of those who support or perform the practice to minimise the resistance of the girls themselves. The medicalization of FGM/C, whereby girls are cut by trained personnel rather than by traditional practitioners, is on the rise. This trend may reflect the impact of campaigns that emphasise the health risks associated with the practice, but fail to address the underlying motivations for its perpetuation. Analysing survey data by age group reveals that in Egypt, Guinea and Mali, the medicalization of FGM/C has increased dramatically in recent years. The importance of the ceremonial aspects associated with FGM/C is declining in many communities. This trend may also be related, in part, to the existence of legislation to prohibit FGM/C that discourages public manifestations of the practice. Magnitude, Assessment and Measurement 7
Standardizing indicators for situation analysis and monitoring progress The information contained in this section represents only a brief introduction to the data on FGM/C available from DHS and MICS. The questions posed in these surveys enable a range of inter- and intracountry comparisons to be carried out. The potential for comparison is further enhanced as these surveys move towards a set of standardised indicators for situation analysis and monitoring progress towards ending FGM/C. In November 2003, international agreement was reached on appropriate indicators for these purposes at a UNICEF Global Consultation on Indicators. 25 At this consultation, five standard indicators for situation analysis were established. 1. Prevalence of FGM/C by age cohorts 15-49. This is the most important indicator. Age cohorts are 15-19, 20-24, 25-29, 30-34, 35-39, 40-44 and 45-49. 2.FGM/C status of all daughters. This indicator refers to FGM/C prevalence for all daughters of mothers aged 15 to 49 years. It is recommended to collect data on the current age of daughters as well as on the age at which they were cut. 3. Percentage of closed FGM/C (infibulation, sealing) and open FGM/C (excision). This simplified category is introduced to help overcome the difficulty of identifying the specific type of FGM/C a woman or her daughter has undergone. 4. Performer of FGM/C. 5.Support of, or opposition to FGM/C by women and men age 15-49. The Global Consultation also sought to extend the collection of data on prevalence to girls aged 5 to 14. It may be possible to obtain these data through local surveys, although these do not yield prevalence data at national levels. To assess the effectiveness of programmes promoting the abandonment of FGM/C, three indicators were agreed upon. Public declaration of intent. The questions should capture the stated intent of individuals, communities and villages to abandon FGM/C. Forms of public declarations may vary from one community to another. Community-based monitoring mechanisms to follow up on girls at risk of FGM/C. Information should be gathered from the community through the health and school systems and from youth groups, along with other community-selected monitoring mechanisms. Information might include the number of girls who have or have not been cut, the age at which the practice is carried out (and any changes in this age), the number of men who would marry women who have not undergone FGM/C, and the dissemination of messages by community members and former practitioners. Drop in prevalence.this is the ultimate quantitative measure that demonstrates progress towards the abandonment of FGM/C and hence the effectiveness of programmes in place. It can be obtained though household surveys organized with international support (MICS or DHS) or locally. Data measuring these indicators can be derived from smaller community studies and programme monitoring and evaluation. Communities should be involved throughout any evaluation process in order to identify indicators and information that reflect their own perception of progress. 8 Magnitude, Assessment and Measurement
Notes 1 See, for example, WHO (2000), Female Genital Mutilation. Fact sheet no. 241, World Health Organization, Geneva. 2 It has been calculated that in 2000, approximately 3,050,000 were girls cut on the African continent. Figure courtesy of Stan Yoder, Measure DHS, ORC Macro. This figure is derived by taking the number of females born in 2000 in these countries, calculating a loss due to infant mortality, and multiplying the resulting figure by the prevalence of FGM/C among the 15-24 year old cohort in each of the countries where FGM/C is performed. The resulting figure is approximate, in part because there are no figures for prevalence among girls of less than 15 years of age, and in part because there is uncertainty over FGM/C prevalence in a number of countries (DRC, The Gambia, Liberia, Senegal, Sierra Leone and southern Sudan). 3 Amnesty International (1998), Section 1: What is Female Genital Mutilation, Female Genital Mutilation A Human Rights Information Pack, www.amnesty.org/ailib/intcam/ femgen/fgm1.htm#a3, accessed 10.2.2005. 4 Demographic and Health Survey, Niger, 1998: Women aged 15-49, and Demographic and Health Survey, Guinea, 1999: Women aged 15-49. 5 Provisional 2004 DHS data indicates a prevalence of approximately 1% in Cameroon. 6 Yoder, P. Stanley, Noureddine Abderrahim and Arlinda Zhuzhuni, Female Genital Cutting in the Demographic and Health Surveys: A Critical and Comparative Analysis, DHS Comparative Reports No. 7, September 2004, ORC Macro. See also UNICEF (2004), The State of the World s Children 2005, The United Nations Children s Fund, New York, Table 9. 7 Table compiled by the UNICEF Strategic Information Section, Division of Policy and Planning. *Data for Egypt, Yemen, and Sudan are based on a sample of ever-married women. It is assumed that FGM/C prevalence rate is no different among non-married women. 8 For more information on Demographic and Health Surveys, see www.measuredhs.com. 9 There are currently 25 Demographic and Health Surveys that contain data on FGM/C (another two contain figures that are still provisional), including countries in which 2 surveys have been carried out. 10 In most countries, the survey includes all women in the 15-49 cohort, however in DHS surveys for Egypt and Yemen, the sample includes only ever-married women in this age group. 11 For a more detailed discussion of the issues introduced in this section, see Yoder, P. Stanley, Noureddine Abderrahim and Arlinda Zhuzhuni, Female Genital Cutting in the Demographic and Health Surveys: A Critical and Comparative Analysis, DHS Comparative Reports No. 7, September 2004, ORC Macro. 12 All data from Multiple Indicator Cluster Survey 2, Central African Republic, 2000. 13 Yoder, P. Stanley, Noureddine Abderrahim and Arlinda Zhuzhuni, Female Genital Cutting in the Demographic and Health Surveys: A Critical and Comparative Analysis, DHS Comparative Reports No. 7, September 2004, ORC Macro. Considering the education level of a woman who has been cut is not helpful, since cutting nearly always takes place before a girls education is complete, and in some cases, even before it begins. 14 Table based on Demographic and Health Survey data, from Yoder, P. Stanley, Noureddine Abderrahim and Arlinda Zhuzhuni, Female Genital Cutting in the Demographic and Health Surveys: A Critical and Comparative Analysis, DHS Comparative Reports No. 7, September 2004, ORC Macro. 15 Demographic and Health Survey, Egypt, 1995 and 2000. 16 Demographic and Health Survey, Ethiopia, 2000; Mali, 2001; Mauritania, 2000-01. 17 Bayoumi, Ahmed (2003), Baseline Survey on FGM Prevalence and Cohort Group Assembly in Three CFCI Focus States, UNICEF Sudan Country Office, Khartoum. 18 Excision of the prepuce, with or without excision of part or all of the clitoris. This refers to the original WHO classification, currently under review. 19 Demographic and Health Survey, Burkina Faso, 1998-99. 20 Surveys were conducted in northern Sudan. 21 Surveys were conducted in northern Sudan. 22 Surveys were conducted in northern Sudan. 23 Yoder, P. Stanley, Noureddine Abderrahim and Arlinda Zhuzhuni, Female Genital Cutting in the Demographic and Health Surveys: A Critical and Comparative Analysis, DHS Comparative Reports No. 7, September 2004, ORC Macro. 24 Yoder, P. Stanley, Noureddine Abderrahim and Arlinda Zhuzhuni, Female Genital Cutting in the Demographic and Health Surveys: A Critical and Comparative Analysis, DHS Comparative Reports No. 7, September 2004, ORC Macro. 25 UNICEF (2004), UNICEF Global Consultation on Indicators, November 11-13, 2004, NYHQ. Child Protection Indicators Framework. Female Genital Mutilation and Cutting, New York, USA, 12 July, 2004 revision. Magnitude, Assessment and Measurement 9
UNICEF/MENA/2004/1292/Ellen Gruenbaum 10
3THE SOCIAL DYNAMICS OF FGM/C In every society in which it is practiced, FGM/C is a manifestation of gender inequality that is deeply entrenched in social, economic and political structures. In practice, however, this dimension is not explicitly addressed and may not even be recognised by those who support and perpetuate FGM/C. Researchers seeking to understand how and why the practice of FGM/C persists are confronted with what appears to be a paradox: in many cases, parents and other family members are perpetuating a tradition that they know can bring harm, both physical and psychological, to their daughters. The explanation lies in the social dynamics among individuals in communities that practice FGM/C. Mothers organize the cutting of their daughters because they consider that this is part of what they must do to raise a girl properly 1 and to prepare her for adulthood and marriage. In discussions about FGM/C, Maninka women in central Guinea explained that parents have a threefold obligation to their daughters: to educate them properly, cut them, and find them a husband. 2 This obligation can be understood as a social convention to which parents conform, even if the practice inflicts harm. From this perspective, not conforming would bring greater harm, since it would lead to shame and social exclusion. Social convention is so powerful that girls themselves may desire to be cut, as a result of the social pressure from peers and because of fear not without reason of stigmatisation and rejection by their own communities if they do not follow the tradition. 3 FGM/C is an important part of girls and women s cultural gender identity and the procedure may also impart a sense of pride, of coming of age and a feeling of community membership. Girls who undergo the procedure are provided with rewards, including celebrations, public recognition and gifts. Moreover, in communities where FGM/C is almost universally practiced, not conforming to the practice can result in stigmatization, social isolation and difficulty in finding a husband. Girls and women living in immigrant communities may also value the procedure because it can play a role in reinforcing their cultural identity in a foreign context. Understanding FGM/C as a social convention provides insight as to why women who have themselves been cut and suffer the health consequences favour its continuation. 4 They resist initiatives to end FGM/C, not because they are unaware of its harmful aspects, but because its abandonment is perceived to entail loss of status and protection. This also helps to explain why individual families that voice a desire to abandon the practice nonetheless submit their daughters to the procedure. The convention can only be changed if a significant number of families within a community make a collective and coordinated choice to abandon the practice so that no single girl or family is disadvantaged by the decision. 5 Mechanisms that reinforce the social convention The justifications offered for the practice of FGM/C are numerous and, in their specific context, compelling. While these justifications may vary among communities, they follow a number of common themes: FGM/C ensures a girl s or woman s status, marriageability, chastity, health, beauty and family honour. In some cases they are presented positively to emphasise the advantages of undergoing FGM/C, The social dynamics of FGM/C 11